Doctors and nurses need better support when they make errorsAn additional perspective by Eric Schulze, CERM on this article posted on KevinMD.

“In September 2010, a seasoned pediatric intensive care unit nurse administered an accidental overdose to a critically ill baby, giving ten times the amount of calcium that was prescribed. Five days later, this baby, with an already tenuous heart condition, died. The nurse recognized her mistake immediately, informed her superior, and also told the family and physicians. She was, however, escorted out of the hospital, put on administrative leave, and fired soon thereafter. In April 2011, she took her own life."​by: Nina Shapiro, MD

Reread the title to the article I reference, Doctors and nurses need better support when they make errors. I agree doctors and nurses do need better support, and in more ways than Nina Shapiro, MD writes about.

Most hospitals do not completely understand the “process approach” or process management. Corrective actions that I review usually consist of actions to write a new policy, update a policy, or retrain. These actions focus on fixing people’s actions and not addressing what caused the problem.

Understanding process requires us to understand all the interrelated and interacting activities that occur to achieve our intended outcome. Most hospitals do not have that level of granular knowledge about themselves. Too often during a RCA, an “expert” at the table throws out the reason why the incident occurred and how to fix it, then moving on to the next problem. That is not causal analysis; it is more about blame analysis.

A seasoned pediatric intensive care nurse administered 10 times the prescribed dose of calcium. A number of process interactions and activities that supported that nurse had occurred before she even had the medication in her hand. What tools were used to perform the causal analysis that determined that the nurse was the reason the medication error occurred? How much analysis of process capability for the core and support processes occurred?

To err is human is true AND if you put a good person in a broken process, the broken process will win. Unfortunately, this event caused heartache and despair for many people. If the true cause of the problem was in fact not the nurse, then there is a probable chance that the processes that led up to this unfortunate event will contribute to harming additional patients at this hospital. If we are to learn from our mistakes, we have to understand what actually caused them.

Doctors and nurses do need more support when they make errors because most likely it was a process or multiple process failures that let them down. BlueSynergy Associates has a page about our philanthropy on our website. The Emily Jerry foundation is one of the charities we support. The event I just wrote about mirrors a similar event with a child named Emily that dies from an overdose from an improperly compounded saline solution. You can read more about the foundation here. We have a link to the story about Emily and the preventable error that took her life.

To read the original article by Nina Shapiro, MD, click on the link below